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Chaigneau M, Grabell J, Wijnker E, Bowman M, James P. Haemophilia testing of young girls in Canada: Describing the current recommendations for factor level and genetic testing and the experiences of Canadian parents. Haemophilia 2024. [PMID: 39368063 DOI: 10.1111/hae.15107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2024] [Revised: 09/05/2024] [Accepted: 09/23/2024] [Indexed: 10/07/2024]
Abstract
INTRODUCTION It is widely acknowledged that haemophilia affects women and girls, yet current testing recommendations for factor level and genetic testing vary and do not universally incorporate updated research. Canadian parents have expressed frustration at inconsistent recommendations and reported instances where delayed testing led to missed diagnosis and preventable bleeding. AIM Study aim was to explore and describe the practice of haemophilia-related testing of young girls in Canada. METHODS A mixed methods study was carried out with two populations: (1) Nurses working in haemophilia care completed a survey regarding the current testing recommendations of their Haemophilia Treatment Centre (HTC), (2) Parents of obligate or potential haemophilia carriers completed a structured interview with questions about their family experience of haemophilia and testing decisions for daughters. RESULTS Twenty-six survey responses were received and showed wide variation in the usual recommendations of Canadian HTCs. Different factor level testing recommendations may be given to obligate and potential carriers despite no difference in bleeding risk. Only a minority of HTCs currently recommend an early baseline factor level (< 10 years) to obligate carriers (27%) or potential carriers (15%). For genetic testing of potential carriers, 70% of HTC would approve a family request for genetic testing of a minor with specific conditions. The majority of parents interviewed felt dissatisfied with their testing experience (58%) and highlighted many issues related to delayed testing recommendations. CONCLUSION Updated, nationally affirmed testing recommendations are needed that align with research on bleeding in women and girls affected by haemophilia.
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Affiliation(s)
- Megan Chaigneau
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Julie Grabell
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Emil Wijnker
- Canadian Hemophilia Society, Queen's University, Kingston, Ontario, Canada
| | - Mackenzie Bowman
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Paula James
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
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2
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Shen K, Chen T, Xiao M. MYH9-related inherited thrombocytopenia: the genetic spectrum, underlying mechanisms, clinical phenotypes, diagnosis, and management approaches. Res Pract Thromb Haemost 2024; 8:102552. [PMID: 39309229 PMCID: PMC11415342 DOI: 10.1016/j.rpth.2024.102552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2024] [Revised: 07/16/2024] [Accepted: 07/24/2024] [Indexed: 09/25/2024] Open
Abstract
Inherited thrombocytopenias have been considered exceedingly rare for a long time, but recent advances have facilitated diagnosis and greatly enabled the discovery of new causative genes. MYH9-related disease (MYH9-RD) represents one of the most frequent forms of inherited thrombocytopenia, usually presenting with nonspecific clinical manifestations, which renders it difficult to establish an accurate diagnosis. MYH9-RD is an autosomal dominant-inherited thrombocytopenia caused by deleterious variants in the MYH9 gene encoding the heavy chain of nonmuscle myosin IIA. Patients with MYH9-RD usually present with thrombocytopenia and platelet macrocytosis at birth or in infancy, and most of them may develop one or more extrahematologic manifestations of progressive nephritis, sensorial hearing loss, presenile cataracts, and elevated liver enzymatic levels during childhood and adult life. Here, we have reviewed recent advances in the study of MYH9-RD, which aims to provide an updated and comprehensive summary of the current knowledge and improve our understanding of the genetic spectrum, underlying mechanisms, clinical phenotypes, diagnosis, and management approaches of this rare disease. Importantly, our goal is to enable physicians to better understand this rare disease and highlight the critical role of genetic etiologic analysis in ensuring accurate diagnosis, clinical management, and genetic counseling while avoiding ineffective and potentially harmful therapies for MYH9-RD patients.
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Affiliation(s)
- Kefeng Shen
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ting Chen
- Department of Ophthalmology, The Sixth Hospital of Wuhan, Affiliated Hospital of Jianghan University, Wuhan, China
| | - Min Xiao
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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3
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VanderMeulen H, Tang GH, Sholzberg M. Tranexamic acid for management of heavy vaginal bleeding: barriers to access and myths surrounding its use. Res Pract Thromb Haemost 2024; 8:102389. [PMID: 38623473 PMCID: PMC11017359 DOI: 10.1016/j.rpth.2024.102389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 03/09/2024] [Accepted: 03/11/2024] [Indexed: 04/17/2024] Open
Abstract
Tranexamic acid is safe and effective for the treatment of heavy vaginal bleeding during menstruation and childbirth. It improves the quality of life, facilitates participation in school and work, and reduces the risk of death from postpartum hemorrhage. Despite its well-established benefits, individual- and structural-level barriers preclude its widespread utilization, hindering effective patient care and perpetuating health inequities in women's health. We first describe the evidence for the use of tranexamic acid in treating heavy menstrual bleeding and postpartum hemorrhage. Barriers to tranexamic acid use, including structural sexism, period poverty, misinformation in product monograph labeling, stigmatization of vaginal blood loss, and drug access, are then discussed. Finally, we summarize relevant data presented during the 2023 International Society on Thrombosis and Haemostasis Congress.
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Affiliation(s)
- Heather VanderMeulen
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Grace H. Tang
- Department of Hematology, Hematology-Oncology Clinical Research Group, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Michelle Sholzberg
- Department of Medicine and Laboratory Medicine & Pathobiology, St. Michael’s Hospital, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
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4
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Casari C, Leung J, James PD. New and emerging therapies for women, girls, and people with the potential to menstruate with VWD. Blood Adv 2023; 7:7501-7505. [PMID: 37967378 PMCID: PMC10758707 DOI: 10.1182/bloodadvances.2023010716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 10/24/2023] [Accepted: 11/09/2023] [Indexed: 11/17/2023] Open
Abstract
Innovation in therapies for patients with von Willebrand disease (VWD) has lagged far behind that for hemophilia, creating inequity in the bleeding disorder community. Although currently existing treatments of antifibrinolytics, desmopressin, and plasma-derived von Willebrand factor replacement are considered effective, multiple studies report poor quality of life in patients with VWD, especially those with heavy menstrual bleeding (HMB). This disconnect underscores the need for novel therapies that are safe and effective and that consider a patient's specific contraceptive and reproductive needs. Recombinant von Willebrand factor is the most recent new therapy for VWD; the data specific to women are reviewed. We also present emerging data on emicizumab for the treatment of VWD, BT200 (rondoraptivon pegol), generalized hemostatic therapies (VGA039 and HMB-011), as well as treatments based on nanotechnology (platelet-inspired nanoparticles and KB-V13A12). We are optimistic as we move toward pivotal clinical trials for these elegant and innovative treatments.
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Affiliation(s)
- Caterina Casari
- Université Paris-Saclay, INSERM, Hémostase Inflammation Thrombose HITH U1176, Le Kremlin-Bicêtre, France
| | - Jennifer Leung
- Department of Medicine, Queen’s University, Kingston, ON, Canada
| | - Paula D. James
- Department of Medicine, Queen’s University, Kingston, ON, Canada
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5
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Tang GH, Thachil J, Bowman M, Bekdache C, James PD, Sholzberg M. Patient-centered care in von Willebrand disease: are we there yet? Expert Rev Hematol 2023; 16:641-649. [PMID: 37581602 DOI: 10.1080/17474086.2023.2243386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 07/28/2023] [Indexed: 08/16/2023]
Abstract
INTRODUCTION Von Willebrand Disease is the most common inherited bleeding disorder. Paradoxically, affected individuals are often misdiagnosed and experience substantial diagnostic delay. There are sex-specific health disparities in VWD rooted in the stigmatization of vaginal bleeding, which leads to symptom dismissal, lack of timely access to care and lower health-related quality of life. AREAS COVERED Following the core elements of patient-centered care - respect for patient preferences, values, and needs, we describe the current state of VWD care. Challenges of diagnostic delay, serial misrecognition of abnormal bleeding, and symptom dismissal are barriers that disproportionately affect women with VWD. These negative effects are further amplified in individuals living in low- and middle-income countries. We describe the importance of coordinated multidisciplinary care, as well as the need for patient education and empowered self-advocacy. EXPERT OPINION While tremendous work has been done to improve the diagnosis and management of VWD, timely and high-quality research is urgently needed to address care gaps. Systemic changes such as resource investment, dedicated research funding for novel treatment modalities, and effective knowledge translation strategies to address structural barriers are needed to facilitate effective patient-centered care for VWD.
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Affiliation(s)
- Grace H Tang
- Hematology-Oncology Clinical Research Group, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Jecko Thachil
- Department of Hematology, Manchester University Hospitals, Manchester, UK
| | - Mackenzie Bowman
- Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Carine Bekdache
- Hematology-Oncology Clinical Research Group, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Paula D James
- Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Michelle Sholzberg
- Department of Medicine and Laboratory Medicine & Pathobiology, St. Michael's Hospital, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
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6
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Leung J, James P. Commentary on Laffan et al expert consensus for equitable care for VWD. Haemophilia 2023; 29:693-694. [PMID: 37134264 DOI: 10.1111/hae.14795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 04/18/2023] [Accepted: 04/19/2023] [Indexed: 05/05/2023]
Affiliation(s)
- Jennifer Leung
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Paula James
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
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7
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Ragni MV, Young G, Batsuli G, Bisson E, Carpenter SL, Croteau SE, Cuker A, Curtis RG, Denne M, Ewenstein B, Federizo A, Frick N, Funkhouser K, George LA, Hoots WK, Jobe SM, Krava E, Langmead CJ, Lewis RJ, López J, Malec L, Mann Z, Miles ME, Neely E, Neufeld EJ, Pierce GF, Pipe SW, Pitler LR, Raffini L, Schnur KM, Shavit JA. Building the foundation for a community-generated national research blueprint for inherited bleeding disorders: facilitating research through infrastructure, workforce, resources and funding. Expert Rev Hematol 2023; 16:107-127. [PMID: 36920855 DOI: 10.1080/17474086.2023.2181781] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 02/14/2023] [Indexed: 03/16/2023]
Abstract
BACKGROUND The National Hemophilia Foundation (NHF) conducted extensive, inclusive community consultations to guide prioritization of research in coming decades in alignment with its mission to find cures and address and prevent complications enabling people and families with blood disorders to thrive. RESEARCH DESIGN AND METHODS With the American Thrombosis and Hemostasis Network, NHF recruited multidisciplinary expert working groups (WG) to distill the community-identified priorities into concrete research questions and score their feasibility, impact, and risk. WG6 was charged with identifying the infrastructure, workforce development, and funding and resources to facilitate the prioritized research. Community input on conclusions was gathered at the NHF State of the Science Research Summit. RESULTS WG6 detailed a minimal research capacity infrastructure threshold, and opportunities to enable its attainment, for bleeding disorders centers to participate in prospective, multicenter national registries. They identified challenges and opportunities to recruit, retain, and train the diverse multidisciplinary care and research workforce required into the future. Innovative collaborative approaches to trial design, resource networking, and funding to surmount obstacles facing research in rare disorders were elucidated. CONCLUSIONS The innovations in infrastructure, workforce development, and resources and funding proposed herein may contribute to facilitating a National Research Blueprint for Inherited Bleeding Disorders.
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Affiliation(s)
- Margaret V Ragni
- Department of Hematology/Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Medical and Scientific Advisory Council, National Hemophilia Foundation, New York, New York, USA
| | - Guy Young
- Cancer and Blood Disorders Institute, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Glaivy Batsuli
- Department of Pediatrics, Emory University, Atlanta, Georgia, USA
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Emily Bisson
- Hemostasis & Thrombosis Center, Connecticut Children's, Hartford, Connecticut, USA
| | - Shannon L Carpenter
- Department of Pediatric Hematology/Oncology, Children's Mercy Hospital, Kansas City, Missouri, USA
| | - Stacy E Croteau
- Boston Hemophilia Treatment Center, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Adam Cuker
- Penn Comprehensive Hemophilia Program, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Randall G Curtis
- Hematology Utilization Group Study (HUGS), University of Southern California, Los Angeles, California, USA
- Patient Reported Outcomes, Burdens and Experiences (PROBE) Washington, DC, USA
| | - Michael Denne
- Hematology and Rare Disease, Takeda, Cincinnati, Ohio, USA
| | - Bruce Ewenstein
- Takeda Development Center Americas, Inc, Cambridge, Massachusetts, USA
| | - Amber Federizo
- Hemostasis and Thrombosis Center of Nevada, Las Vegas, Nevada, USA
| | - Neil Frick
- National Hemophilia Foundation, New York, New York, USA
| | - Kerry Funkhouser
- Foundation for Women & Girls with Blood Disorders, Montclair, New Jersey, USA
| | - Lindsey A George
- Department of Hematology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - W Keith Hoots
- Division of Blood Diseases and Resources, National Heart, Lung and Blood Institute, National Institutes of Health; Health and Human Services, Bethesda, Maryland, USA
| | - Shawn M Jobe
- Department of Pediatrics and Human Development, Michigan State University College of Medicine, East Lansing, Michigan, USA
| | - Emily Krava
- Department of Hematology-Oncology, Children's Hospital Los Angeles, Los Angeles, California, USA
| | | | | | - José López
- Bloodworks Northwest, Seattle, Washington, USA
- Department of Hematology, University of Washington, School of Medicine, Seattle, Washington, USA
| | - Lynn Malec
- Blood Research Institute, Versiti, Milwaukee, Wisconsin, USA
| | - Ziva Mann
- National Hemophilia Foundation, New York, New York, USA
- Ascent Leadership Networks, Newton, Massachusetts, USA
| | - Moses E Miles
- American Thrombosis and Hemostasis Network, Rochester, New York, USA
| | - Emma Neely
- National Hemophilia Foundation, New York, New York, USA
| | - Ellis J Neufeld
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
- Department of Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Glenn F Pierce
- World Federation of Hemophilia, Montréal, Québec, Canada
| | - Steven W Pipe
- Medical and Scientific Advisory Council, National Hemophilia Foundation, New York, New York, USA
- Division of Pediatric Hematology and Oncology, University of Michigan, Ann Arbor, Michigan, USA
| | - Lisa R Pitler
- Alliance for Clinical Trials in Oncology Foundation, Chicago, Illinois, USA
| | - Leslie Raffini
- Hemostasis and Thrombosis Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Kathaleen M Schnur
- Hemophilia Center of Western Pennsylvania, Pittsburgh, Pennsylvania, USA
| | - Jordan A Shavit
- Division of Pediatric Hematology and Oncology, University of Michigan, Ann Arbor, Michigan, USA
- Human Genetics, University of Michigan, Ann Arbor
- Hemophilia and Coagulation Disorders Program, University of Michigan, Ann Arbor, Michigan, USA
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8
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Baldwin MK, Ahmadzia HK, Bartlett DL, Bensen-Kennedy D, Desai V, Haley KM, Herman-Hilker SL, Kilgore AM, Kulkarni R, Lavin M, Luckey S, Matteson KA, Paulyson-Nuñez K, Philipp CS, Ragosta S, Rosen K, Rotellini D, Weyand AC. Building the foundation for a community-generated national research blueprint for inherited bleeding disorders: research to advance the health of people with inherited bleeding disorders with the potential to menstruate. Expert Rev Hematol 2023; 16:71-86. [PMID: 36920864 PMCID: PMC10020871 DOI: 10.1080/17474086.2023.2175660] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 01/30/2023] [Indexed: 03/16/2023]
Abstract
BACKGROUND People who have or had the potential to menstruate (PPM) with inherited bleeding disorders (BD) face particular challenges receiving appropriate diagnosis and care and participating in research. As part of an initiative to create a National Research Blueprint for future decades of research, the National Hemophilia Foundation (NHF) and American Thrombosis and Hemostasis Network conducted extensive all-stakeholder consultations to identify the priorities of PPM with inherited BDs and those who care for them. RESEARCH DESIGN AND METHODS Working group (WG) 4 of the NHF State of the Science Research Summit distilled community-identified priorities for PPM with inherited BDs into concrete research questions and scored their feasibility, impact, and risk. RESULTS WG4 identified important gaps in the foundational knowledge upon which to base optimal diagnosis and care for PPM with inherited BDs. They defined 44 top-priority research questions concerning lifespan sex biology, pregnancy and the post-partum context, uterine physiology and bleeding, bone and joint health, health care delivery, and patient-reported outcomes and quality-of-life. CONCLUSIONS The needs of PPM will best be advanced with research designed across the spectrum of sex and gender biology, with methodologies and outcome measures tailored to this population, involving them throughout.
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Affiliation(s)
- Maureen K. Baldwin
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, Oregon, USA
| | - Homa K. Ahmadzia
- Department of Obstetrics and Gynecology, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | | | | | - Vidhi Desai
- CSL Behring, King of Prussia, Pennsylvania, USA
| | - Kristina M. Haley
- The Hemophilia Center, Oregon Health and Science University, Portland, Oregon, USA
- Department of Pediatrics, Oregon Health and Science University, Portland, Oregon, USA
| | - Sherry L. Herman-Hilker
- Hemophilia and Coagulation Disorders Program, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Roshni Kulkarni
- MSU Center of Bleeding and Clotting Disorders, Department Pediatrics and Human Development, Michigan State University, East Lansing, Michigan, USA
| | - Michelle Lavin
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
- National Coagulation Centre, St. James’s Hospital, Dublin, Ireland
| | - Shari Luckey
- Hemophilia Foundation of Michigan, Ypsilanti, Michigan, USA
| | - Kristen A. Matteson
- Department of Obstetrics and Gynecology, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Kristin Paulyson-Nuñez
- Duke Health Women & Children’s Services, Duke University Health Systems, Durham, North Carolina, USA
| | - Claire S. Philipp
- Division of Hematology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | | | - Kimberly Rosen
- Bayer HealthCare Pharmaceuticals, Whippany, New Jersey, USA
| | | | - Angela C. Weyand
- Division of Pediatric Hematology and Oncology, University of Michigan Medical School, Ann Arbor, Michigan, USA
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9
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VanderMeulen H. What have we learned about the patient's experience of von Willebrand disease? A focus on women. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2022; 2022:631-636. [PMID: 36485077 PMCID: PMC9820129 DOI: 10.1182/hematology.2022000391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Von Willebrand disease (VWD), the most common inherited bleeding disorder (IBD), disproportionately affects females, given the hemostatic challenges they may encounter throughout their lifetimes. Despite this, research about VWD remains grossly underrepresented, particularly compared to hemophilia, which is historically diagnosed in males. Structural sexism, stigmatization of menstrual bleeding, delayed diagnosis, and a lack of timely access to care result in an increased frequency of bleeding events, iron deficiency, iron deficiency anemia, and a decreased quality of life. However, we are only beginning to recognize and acknowledge the magnitude of the burden of this disease. With an increasing number of studies documenting the experiences of women with IBDs and recent international guidelines suggesting changes to optimal management, a paradigm shift in recognition and treatment is taking place. Here, we present a fictional patient case to illustrate one woman's history of bleeding. We review the evidence describing the impact of VWD on quality of life, normalization of vaginal bleeding, diagnostic delays, and the importance of access to multidisciplinary care. Furthermore, we discuss considerations around reproductive decision-making and the intergenerational nature of bleeding, which often renders patients as caregivers. Through incorporating the patient perspective, we argue for an equitable and compassionate path to overcome decades of silence, misrecognition, and dismissal. This path moves toward destigmatization, open dialogue, and timely access to specialized care.
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Affiliation(s)
- Heather VanderMeulen
- Canadian Blood Services, Toronto, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada
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10
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Chaigneau M, Botros M, Grabell J, Hopman W, James P. Challenges and knowledge gaps facing hemophilia carriers today: Perspectives from patients and health care providers. Res Pract Thromb Haemost 2022; 6:e12783. [PMID: 36186104 PMCID: PMC9487445 DOI: 10.1002/rth2.12783] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 06/07/2022] [Accepted: 07/22/2022] [Indexed: 11/07/2022] Open
Abstract
Background Hemophilia carriers experience abnormal bleeding symptoms; however, a lack of awareness about this topic coupled with additional knowledge gaps and barriers leads to suboptimal care for this population. Objective The primary objective was to describe the current knowledge gaps and challenges from the perspective of both hemophilia carriers and their health care providers. Methods We carried out a mixed methods descriptive study with two population groups between September and December 2020. The hemophilia carrier perspective was obtained through both focus groups and questionnaires, whereas the health care providers perspective obtained via questionnaire sent to the Association of Hemophilia Care Directors of Canada and the Canadian Association of Nurses in Hemophilia Care. Focus groups were analyzed using descriptive thematic analysis and quantitative survey data was also analyzed. Results Eleven hemophilia carriers participated along with 19 health care providers (11 physicians, eight nurses). Hemophilia carrier focus group discussions identified four areas representing major challenges or knowledge gaps: (1) negative psychosocial impacts; (2) difficulty determining symptom significance; (3) need for self-advocacy; (4) testing concerns. Survey results from both groups were aligned with the most important topics for ongoing education identified as information on abnormal bleeding symptoms, where to seek treatment, and considerations for heavy menstrual bleeding/menstruation. The majority of both study groups believe obligate or potential carriers should have factor levels checked regardless of age if symptoms of abnormal bleeding occur or before an invasive procedure. However, hemophilia carriers were significantly more in favor of genetic testing under the age of consent than health care providers in all scenarios evaluated.
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Affiliation(s)
| | | | - Julie Grabell
- Deparment of MedicineQueen's UniversityKingstonOntarioCanada
| | - Wilma Hopman
- KGH Research InstituteKingstonOntarioCanada
- Department of Public Health SciencesQueen's UniversityKingstonOntarioCanada
| | - Paula James
- Deparment of MedicineQueen's UniversityKingstonOntarioCanada
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11
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Parker M, Hannah M, Zia A. “If I wasn't a girl”: Experiences of adolescent girls with heavy menstrual bleeding and inherited bleeding disorders. Res Pract Thromb Haemost 2022; 6:e12727. [PMID: 35664533 PMCID: PMC9152438 DOI: 10.1002/rth2.12727] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 03/24/2022] [Accepted: 03/29/2022] [Indexed: 11/09/2022] Open
Abstract
Background Heavy menstrual bleeding (HMB) is a presenting symptom of an inherited bleeding disorder (BD) and results in hospitalizations, limitations of daily activities, and a reduction in quality of life. Adult women with BD report a sense of stigma, difficulties understanding their bleeding, and challenges with diagnostic labels. The experiences of adolescents with HMB and BD are unknown despite advances in medical management through the rapidly growing network of young women's hematology programs. Objectives The objective of our qualitative study was to describe the experiences of adolescents with HMB with a BD and the impact on their day‐to‐day lives. Patients/Methods Our qualitative study utilized semistructured interviews with adolescents with HMB after a BD diagnosis. We included adolescents with a BD within a multidisciplinary Young Women's Bleeding Disorders Clinic who had achieved menarche within the preceding 3 years and conducted interviews until theme saturation. All interviews were transcribed verbatim and analyzed using qualitative thematic descriptive analysis. Results We identified the following themes in nine participants: anxiety and embarrassment, especially related to school; isolation and “otherness”; increased cautiousness and planning because of HMB and BD; and empowerment and identity formation because of the diagnosis of a BD. Conclusions Our study uncovers previously unappreciated experiences of adolescents with HMB and a BD. HMB is an isolating and stressful experience in adolescents, but a BD diagnosis results in identity formation and empowerment. Psychological support and facilitating connections to others with similar life experiences soon after diagnosis represents key areas for targeted interventions.
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Affiliation(s)
- Mackenzie Parker
- The University of Texas Southwestern Medical Center Dallas Texas USA
| | - Maria Hannah
- Department of Pediatrics Los Angeles County and University of Southern California Los Angeles California USA
| | - Ayesha Zia
- The University of Texas Southwestern Medical Center Dallas Texas USA
- Departments of Pediatrics The University of Texas Southwestern Medical Center Dallas Texas USA
- Division of Hematology/Oncology The University of Texas Southwestern Medical Center Dallas Texas USA
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12
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Rauch A, Valentino LA, Mills K, Witkop ML, Santaella ME, DiMichele D, Recht M, Susen S. Big picture initiatives in bleeding disorders. Haemophilia 2022; 28 Suppl 4:53-60. [PMID: 35521733 DOI: 10.1111/hae.14532] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 02/22/2022] [Accepted: 02/22/2022] [Indexed: 12/01/2022]
Abstract
INTRODUCTION The inherited bleeding disorders (IBD) community has witnessed significant therapeutic advances recently, yet important gaps persist, particularly for those with rare disorders and historically underserved populations. AIMS -To create a national research blueprint agenda, led by the National Hemophilia Foundation (NHF), enhancing patient-centric principles, accelerate research progress and address important gaps in care. -To review critical gaps that remain to be addressed in women with IBDs, who face specific bleeding challenges. METHODS The NHF research blueprint research agenda was defined by input from across the community, including caregivers and patients who are considered subject matter experts of their IBD, research leaders, allied health professionals and specialists, and representatives of the biopharmaceutical industry. In addition, two medical experts in the field of IBDs performed a comprehensive review to address the knowledge gaps in women with IBDs. RESULTS Two foundational principles of the NHF blueprint are: (1) it must deliver on key issues that significantly impact the lives of those affected by IBDs, and (2) the priorities defined are relevant and actionable aimed to achieve health equity among all those affected by IBDs. A multidisciplinary approach is necessary for an optimal management of puberty, transition to adulthood and pregnancy. Even if strict guidelines are followed, recent studies show that women with IBDs are still facing a high burden. CONCLUSION NHF blueprint will be issued in 2022. A specific research agenda is needed in women with IBDs to further improve their management and quality of life.
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Affiliation(s)
| | - Leonard A Valentino
- National Hemophilia Foundation, New York, New York, USA.,Rush University, Chicago, Illinois, USA
| | - Kevin Mills
- National Hemophilia Foundation, New York, New York, USA
| | | | | | | | - Michael Recht
- American Thrombosis and Hemostasis Network, Rochester, New York, USA
| | - Sophie Susen
- CHU Lille, Hematology Transfusion, LILLE, France
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13
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Weyand AC, Sidonio RF, Sholzberg M. Health issues in women and girls affected by haemophilia with a focus on nomenclature, heavy menstrual bleeding, and musculoskeletal issues. Haemophilia 2022; 28 Suppl 4:18-25. [PMID: 35521724 PMCID: PMC9321707 DOI: 10.1111/hae.14535] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 02/24/2022] [Accepted: 02/24/2022] [Indexed: 12/26/2022]
Abstract
Introduction Women and girls affected by haemophilia, including haemophilia carriers (WGH) are at risk of bleeding symptoms that may go unrecognized, including heavy menstrual bleeding (HMB) and musculoskeletal bleeding. Terminology continues to evolve. Aim To describe the current recommendations for nomenclature surrounding WGH, and the current understanding of HMB, iron deficiency, and musculoskeletal complaints in these patients. Methods Literature was reviewed and summarized. Results With regards to nomenclature, women with factor levels less than 50% should be classified as having haemophilia, while carriers with normal levels should be characterized accordingly to symptomatology. HMB and resultant iron deficiency are common among WGH, have a multitude of downstream effects, and maybe overlooked due to stigma around menstruation. Musculoskeletal bleeding and resultant joint changes are increasingly recognized in this population but do not necessarily correlate with factor levels. Conclusion Although progress has been made in the care of WGH, much work remains to further improve their care.
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Affiliation(s)
- Angela C Weyand
- Department of Pediatrics, Division of Hematology/Oncology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Robert F Sidonio
- Department of Pediatrics, Division of Hematology/Oncology, Emory University, Atlanta, Georgia, USA
| | - Michelle Sholzberg
- Departments of Medicine, and Laboratory Medicine and Pathobiology, St. Michael's Hospital, Li Ka Shing Knowledge Institute, University of Toronto, Toronto, Ontario, Canada
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14
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Byams VR, Miller CH, Bethea FM, Abe K, Bean CJ, Schieve LA. Bleeding Disorders in Women and Girls: State of the Science and CDC Collaborative Programs. J Womens Health (Larchmt) 2022; 31:301-309. [PMID: 35275742 PMCID: PMC11005793 DOI: 10.1089/jwh.2022.0008] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Women and girls with bleeding disorders experience abnormal and excessive bleeding that can negatively impact their overall health and quality of life. In this report, we provide an overview of the biology, types, clinical care, and state of the science related to bleeding disorders in girls and women and describe Centers for Disease Control and Prevention (CDC) activities related to (1) surveillance of bleeding disorders in women; (2) scientific review, research, and collaboration to inform health care gaps in identifying and caring for women with bleeding disorders; and (3) development of health promotion and education programs to bring awareness about bleeding disorders to both women and girls in the population at large and various health care providers who care for women. Findings generated from surveillance and research activities inform the development of new public health programs aimed at improving diagnostic and health care services and empowering women with bleeding disorders with the knowledge they need to navigate a complex health care system with the need for specialty care services. Additional work is needed to improve provider awareness and understanding of the unique needs of women and girls with bleeding disorders to achieve appropriate care and treatment and ensure optimal outcomes and quality of life.
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Affiliation(s)
- Vanessa R. Byams
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA
| | - Connie H Miller
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA
- Synergy America, Inc., Duluth, GA
| | - Fiona M. Bethea
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA
| | - Karon Abe
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA
| | - Christopher J. Bean
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA
| | - Laura A. Schieve
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA
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15
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Arya S, Siad FM, Wilton P, Page D, Boma-Fischer L, Floros G, Winikoff R, Teitel J, Sholzberg M. Invisible bleeds: Lived experiences and barriers to care for men with hemophilia. J Thromb Haemost 2022; 20:296-306. [PMID: 34689399 DOI: 10.1111/jth.15570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 10/10/2021] [Accepted: 10/20/2021] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Guidelines of the World Federation of Hemophilia support the provision of equitable, optimal care for people with hemophilia (PWH). However, limited research exists examining the lived experiences of PWH or the barriers to care they may encounter. The primary objective of this exploratory study was to describe the experiences of men with hemophilia in Canada. METHODS We conducted a qualitative descriptive study using a semistructured interview guide and analyzed transcribed interviews using inductive thematic content analysis. Inclusion criteria were: age ≥18 years, English-speaking, and confirmed diagnosis of inherited hemophilia A or B. RESULTS A total of 11 participants were interviewed. Median age was 39 years old (29-73 years old), and diagnoses included severe hemophilia A (n = 5), mild hemophilia A (n = 2), and severe hemophilia B (n = 4). Three primary themes arose: (1) impact on identity and daily life; (2) dynamic changes in treatment; and (3) barriers to care and identified needs. Major subthemes included chronic pain and activity limitation, psychosocial burden, and symptom normalization. Multidisciplinary care, coordinated surgical care, improved emergency care, and clear care plans were identified as ongoing needs. DISCUSSION Men with hemophilia described significant symptom burden and areas of ongoing need. Collaborative efforts between hematologists, emergency room physicians, and surgeons to establish hospital-specific testing, treatment and referral guidelines, and regular hemophilia treatment center audits may help address these care gaps, providing more person-centered, equitable care. Future work is required to implement these strategies and monitor their effects.
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Affiliation(s)
- Sumedha Arya
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Fartoon M Siad
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - David Page
- Canadian Hemophilia Society, Montreal, QC, Canada
| | | | - Georgina Floros
- Department of Nursing, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Rochelle Winikoff
- Division of Hematology-Oncology, CHU Ste-Justine, Montreal, QC, Canada
| | - Jerome Teitel
- Department of Medicine, University of Toronto, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Michelle Sholzberg
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
- Department of Medicine and Laboratory Medicine & Pathobiology, St. Michael's Hospital, Toronto, Ontario, Canada
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16
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Sanigorska A, Chaplin S, Holland M, Khair K, Pollard D. The lived experience of women with a bleeding disorder: A systematic review. Res Pract Thromb Haemost 2022; 6:e12652. [PMID: 35141459 PMCID: PMC8813663 DOI: 10.1002/rth2.12652] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 11/14/2021] [Accepted: 12/09/2021] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Research studies have described the morbidity associated with inherited bleeding disorders such as hemophilia and von Willebrand disease in women, but their effect on daily living has long been underrecognized. This systematic review sought to document the lived experience of women with a bleeding disorder by assessing research findings on quality of health care, socioeconomic factors, and mental health. METHODS A systematic search was carried out in Web of Science, the Cumulative Index to Nursing and Allied Health Literature, and PubMed on July 31, 2020. References were hand searched. Abstracts of the 2019 and 2020 congresses on bleeding disorders were hand searched. Key journals were screened for relevant studies published after the search date until the analysis was completed on December 7, 2020. RESULTS Of 635 potentially eligible publications, 27 published since 1998 were selected for review. Most studies were of moderate to high quality but meta-analysis of quantitative studies was not possible due to difference in outcomes and assessment.Women with a bleeding disorder experience obstacles to accessing care, difficulties living with their disorder, interference with schooling and work, and poor mental health. Diagnostic delay and lack of recognition of symptoms mean treatment and support may not be available. Where comparisons with controls were made, women's negative experiences were greater than those of men. CONCLUSIONS Women with bleeding disorders experience major negative impacts of their disorders on daily life and mental well-being. Many of the challenges identified in earlier research are evident in more recent studies.
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Affiliation(s)
- Anna Sanigorska
- Oxford Haemophilia and Thrombosis CentreChurchill HospitalOxfordUK
| | | | | | | | - Debra Pollard
- HaemnetLondonUK
- Katharine Dormandy Haemophilia CentreRoyal Free HospitalLondonUK
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17
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Sholzberg M, James PD. Commentary: surviving sexism in bleeding disorders affecting women. Br J Haematol 2021; 196:15-16. [PMID: 34618910 DOI: 10.1111/bjh.17881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 09/20/2021] [Accepted: 09/23/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Michelle Sholzberg
- Departments of Medicine, and Laboratory Medicine and Pathobiology, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Paula D James
- Department of Medicine, Queen's University, Kingston, ON, Canada
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18
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Punt MC, Teela L, Fischer K, Bloemenkamp KWM, Lely AT, Driessens MHE, Pekel L, Haverman L, van Galen KPM. A qualitative study on the experiences of haemophilia carriers before, during and after pregnancy. Haemophilia 2021; 27:e675-e682. [PMID: 34415675 PMCID: PMC9290707 DOI: 10.1111/hae.14396] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 07/25/2021] [Accepted: 08/04/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Haemophilia carriers (HCs) face considerable haemostatic and psychological challenges during reproduction. AIM To explore the perspectives of HCs on healthcare in the current standard of haemophilia treatment during all reproductive phases: preconception, pregnancy, childbirth and the postpartum period. In addition, we examined the psychological impact of haemophilia during these phases. MATERIAL AND METHODS Focus group discussions (FGDs) and semi-structured interviews were conducted with HCs in January/February 2020 until data saturation was reached. All sessions were recorded, transcribed verbatim and analysed by two independent researchers through thematic content analysis using MAXQDA® software. The results were then discussed within the research team until consensus was reached. The constructed themes were shared with and reviewed by the HCs. RESULTS Fifteen HCs were included in three FGDs and four interviews. Five central themes were constructed: (1) communication by healthcare professionals, (2) lack of knowledge, (3) feeling insecure, (4) autonomy and (5) family experiences with haemophilia. Desired improvements in care mainly concerned counselling during preconception and pregnancy. This included timely access to comprehensive information during each consecutive phase, acceptance of HCs' choices by healthcare providers and healthcare tailored to the HC's family experience with haemophilia. CONCLUSIONS In recent years, haemophilia treatment has seen major advances, which could impact general and reproductive care for HCs. HCs indicated that reproductive care would benefit from a more personal and informative approach. Healthcare professionals could use these insights to adapt their consultations to meet the needs of these women when they are preparing for having children.
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Affiliation(s)
- Marieke C Punt
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Lorynn Teela
- Psychosocial Department, Emma Children's Hospital Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Kathelijn Fischer
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Kitty W M Bloemenkamp
- Department of Obstetrics, Birth Centre Wilhelmina's Children Hospital, Division Woman and Baby, Utrecht University, Utrecht, The Netherlands
| | - A Titia Lely
- Department of Obstetrics, Birth Centre Wilhelmina's Children Hospital, Division Woman and Baby, Utrecht University, Utrecht, The Netherlands
| | | | - Lynnda Pekel
- Dutch Society of Haemophilia Patients (NVHP), Nijkerk, The Netherlands
| | - Lotte Haverman
- Psychosocial Department, Emma Children's Hospital Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Karin P M van Galen
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht, The Netherlands
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19
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van Galen K, Lavin M, Skouw-Rasmussen N, Fischer K, Noone D, Pollard D, Mauser-Bunschoten E, Khair K, Gomez K, van Loon E, Bagot CN, Elfvinge P, d'Oiron R, Abdul-Kadir R. European principles of care for women and girls with inherited bleeding disorders. Haemophilia 2021; 27:837-847. [PMID: 34343384 DOI: 10.1111/hae.14379] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 06/29/2021] [Accepted: 07/07/2021] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Despite increasing awareness of issues faced by women and girls with inherited BDs (WGBD), standards of care are lacking, with disparities in diagnosis and treatment for WGBD across Europe. We aimed to develop practical principles of care (PoC) to promote standardization of care for WGBD within European Haemophilia Treatment and Comprehensive Care Centres (HTC/CCCs). METHODS The co-creation process, supported by the European Association for Haemophilia and Allied Disorders, consisted of four multidisciplinary meetings with health care providers (HCPs) experienced in WGBD care, and European Haemophilia Consortium representatives, combined with broad patient and HCP consultations in the European haemophilia community. Relevant medical societies outside Europe were contacted for confirmation. RESULTS We developed ten PoC for WGBD, stressing the importance and benefits of a centralized, multidisciplinary, comprehensive, family-centred approach to support and manage WGBD during all life stages. These PoC emphasise the right to equitable access and quality of care for all people with BDs, irrespective of gender. Multiple medical societies outside Europe also confirmed their support for endorsement. CONCLUSIONS Ten PoC for WGBD evolved from an iterative process among stakeholders, supported by relevant medical societies worldwide. These PoC can serve as a benchmark for diagnosis and comprehensive multidisciplinary management of WGBD, and improve awareness of their unique challenges. They offer a framework to guide HTC/CCCs in providing equitable care for all WGBD, both in their own services and in other healthcare settings. Implementation of these principles aims to positively impact the health, wellbeing and quality of life for WGBD.
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Affiliation(s)
- Karin van Galen
- Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Michelle Lavin
- Irish Centre for Vascular Biology, School of Pharmacy and Biomedical Sciences, RCSI, Dublin and National Coagulation Centre, St. James' Hospital, Dublin, Ireland
| | | | - Kathelijn Fischer
- Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Declan Noone
- President, European Haemophilia Consortium, Brussels, Belgium
| | - Debra Pollard
- Haemophilia Centre and Thrombosis Unit, Royal Free London NHS Foundation Trust, London, UK
| | | | - Kate Khair
- Director of Research, Haemnet, London, UK
| | - Keith Gomez
- Haemophilia Centre and Thrombosis Unit, Royal Free London NHS Foundation Trust, London, UK
| | | | | | - Petra Elfvinge
- Department of Haematology, Karolinska University, Stockholm, Sweden
| | - Roseline d'Oiron
- Centre de Référence de l'Hémophilie et des Maladies Hémorragiques Constitutionnelles, APHP Paris Saclay - Hôpital Bicêtre and Inserm, U 1176 Le Kremlin Bicêtre, France
| | - Rezan Abdul-Kadir
- Department of Obstetrics and Gynaecology, Royal Free London NHS Foundation Trust and Institute for Women's Health, University College London, London, UK
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20
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Abstract
PURPOSE OF REVIEW To summarize the recent literature related to female hemophilia A carriers with respect to prevalence in the population, the impact of baseline factor VIII levels and other influences on bleeding phenotype, and clinical management needs. RECENT FINDINGS Many female hemophilia A carriers are at risk for abnormal bleeding, yet they are underrecognized by healthcare providers and their bleeding symptoms are underreported. Low FVIII levels are consistently associated with clinically significant bleeding and correlate well with skewed X chromosome inactivation (XCI). Most interestingly, bleeding tendency is also observed in some hemophilia A carriers with normal factor VIII levels and requires further investigation. Well controlled studies investigating peripartum and periprocedural FVIII levels and adequate hemostatic treatment are necessary to inform management guidelines. SUMMARY Prevalence and bleeding tendency of hemophilia A carriers remain underreported, despite a significant proportion having low FVIII levels. Skewed XCI may explain low FVIII but does not explain the bleeding risk encountered in a larger proportion of hemophilia A carriers with random XCI and borderline/normal FVIII.
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21
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Arya S, Wilton P, Page D, Boma-Fischer L, Floros G, Winikoff R, Teitel J, Dainty K, Sholzberg M. "They don't really take my bleeds seriously": Barriers to care for women with inherited bleeding disorders. J Thromb Haemost 2021; 19:1506-1514. [PMID: 33774912 DOI: 10.1111/jth.15311] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 03/09/2021] [Accepted: 03/15/2021] [Indexed: 01/27/2023]
Abstract
INTRODUCTION Women with inherited bleeding disorders experience excessive bleeding that may impair their quality of life, making early diagnosis and treatment critical. However, the experiences of these women regarding access to care has been minimally described. The primary objective of this study was to evaluate and describe barriers to care for women with bleeding disorders. This study was a continuation of our previous work describing the lived experiences of these women. METHODS We undertook a qualitative descriptive study. Inclusion criteria for study enrollment were the following: age ≥18 years, English-speaking, and confirmed diagnosis of an inherited bleeding disorder. Women were recruited across Canada by treating health-care providers and members of the Canadian Hemophilia Society. Telephone interviews were conducted using a semi-structured interview style, transcribed verbatim, and analyzed using descriptive thematic analysis. RESULTS A total of 15 participants were interviewed. Median age was 31 years (range 24-70 years). Four primary themes surrounding barriers to care emerged: (1) lack of health-care provider awareness of bleeding disorders, (2) health-care provider dismissal of symptoms, (3) limited access to specialized care and treatment plans, and (4) need for self-education and advocacy. DISCUSSION We found that women with inherited bleeding disorders experience tension with the health-care system, feeling unheard and poorly understood. Based on our findings, we identified key knowledge and care gaps that could be addressed with awareness and educational initiatives: patient education on vaginal blood loss, updated medical curricula, clear referral guidelines, and telehealth initiatives for patients residing far from hemophilia treatment centers.
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Affiliation(s)
- Sumedha Arya
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Pamela Wilton
- Canadian Hemophilia Society, Montreal, Quebec, Canada
| | - David Page
- Canadian Hemophilia Society, Montreal, Quebec, Canada
| | - Laurence Boma-Fischer
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
- Division of Hematology and Oncology, Department of Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Georgina Floros
- Division of Hematology and Oncology, Department of Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
- Department of Nursing, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Rochelle Winikoff
- Division of Hematology-Oncology, CHU Ste-Justine, Montreal, Quebec, Canada
| | - Jerome Teitel
- Division of Hematology and Oncology, Department of Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Katie Dainty
- North York General Hospital, Toronto, Ontario, Canada
- Institute of Health Policy Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Michelle Sholzberg
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
- Department of Medicine and Laboratory Medicine & Pathobiology, St. Michael's Hospital, Toronto, Ontario, Canada
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22
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von Willebrand disease: what does the future hold? Blood 2021; 137:2299-2306. [PMID: 33662989 DOI: 10.1182/blood.2020008501] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 02/09/2021] [Indexed: 12/12/2022] Open
Abstract
von Willebrand disease (VWD) is characterized by its heterogeneous clinical manifestation, which complicates its diagnosis and management. The clinical management of VWD has remained essentially unchanged over the last 30 years or so, using von Willebrand factor (VWF) concentrates, desmopressin, and anti-fibrinolytic agents as main tools to control bleeding. This is in contrast to hemophilia A, for which a continuous innovative path has led to novel treatment modalities. Despite current VWD management being considered effective, quality-of-life studies consistently reveal a higher than anticipated burden of VWD on patients, which is particularly true for women. Apparently, despite our perceived notion of current therapeutic efficiency, there is space for innovation with the goal of reaching superior efficacy. Developing innovative treatments for VWD is complex, especially given the heterogeneity of the disease and the multifunctional nature of VWF. In this perspective article, we describe several potential strategies that could provide the basis for future VWD treatments. These include genetic approaches, such as gene therapy using dual-vector adenoassociated virus and transcriptional silencing of mutant alleles. Furthermore, protein-based approaches to increase factor FVIII levels in VWD-type 3 or 2N patients are discussed. Finally, antibody-based options to interfere with VWF degradation (for congenital VWD-type 2A or acquired von Willebrand syndrome-type 2A) or increase endogenous VWF levels (for VWD-type 1) are presented. By highlighting these potential strategies, we hope to initiate an innovative path, which ultimately would allow us to better serve VWD patients and their specific needs.
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Weyand AC, James PD. Sexism in the management of bleeding disorders. Res Pract Thromb Haemost 2021; 5:51-54. [PMID: 33537529 PMCID: PMC7845070 DOI: 10.1002/rth2.12468] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 11/09/2020] [Accepted: 11/15/2020] [Indexed: 12/24/2022] Open
Abstract
Sexism has been an issue in bleeding disorders for centuries. Women with bleeding disorders have been underrecognized and underdiagnosed. Those who are diagnosed often experience delays in diagnosis and feel that their symptoms are dismissed or minimized. Several factors contribute to this sexism. Historically, the clinical and research focus within the bleeding disorder community has been on men and hemophilia. Von Willebrand disease, a disease that has long been recognized as affecting women, is much more common than hemophilia, yet has significantly fewer resources devoted to it. The lack of knowledge and comfort that patients and health care providers have regarding menstruation compounds the issue, as heavy menstrual bleeding is one of the most common symptoms seen in women with bleeding disorders. Stemming from the universal stigmatization of periods, this lack of comfort and knowledge results in fewer women seeking care, fewer health care providers addressing the issue, and fewer women getting the care they deserve. Progress has been made, with many organizations dedicating resources to improving the care of these women. The road is long, and much more work is needed to ensure that women with bleeding disorders receive the care they deserve.
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Affiliation(s)
- Angela C. Weyand
- Department of PediatricsUniversity of Michigan Medical SchoolAnn ArborMIUSA
| | - Paula D. James
- Department of MedicineQueen’s UniversityKingstonONCanada
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